The Nursing Process
Several nurses from the medical unit access the electronic medical record of a well-known public official who was admitted to the emergency department. How should the nurse manager respond to the nurses regarding this situation? "It is understandable that you would be interested in the official's medical status." "Accessing the official's medical record is a breach of confidentiality." "You must not share the information you learn with others outside this unit." "We must maintain the official's confidentiality by denying that the official is a client here."
"Accessing the official's medical record is a breach of confidentiality."
A nurse is caring for a terminally ill client in the home. The family wants to know how to respond when the client asks whether the client is dying. Which is the best response by the nurse? "Answer truthfully in a caring, gentle manner." "Use this opportunity to ask how the client feels about death." "Say that only God knows what is in store for everyone." "Offer some hope to keep the client strong during this time."
"Answer truthfully in a caring, gentle manner."
A hospital uses the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? "Client reporting abdominal pain rated at 8/10." "Client is guarding abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone PO administered with good effect."
"Client reporting abdominal pain rated at 8/10."
A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data? "Client vomited 250 mL of yellow liquid." "Client's respiratory rate was 8 and labored." "Client seems very nauseated." "Promethazine 25 mg IM is administered."
"Client seems very nauseated."
A new nurse will be monitoring a client during a moderate sedation procedure for the first time, and is discussing this with the charge nurse. Which statement made by the newly graduated nurse will the charge nurse verify as accurate? "It is unnecessary to monitor both capnography and pulse oximetry; just one or the other is adequate." "Cardiac monitoring is not needed because moderate sedation medications are not high-risk medications." "Complete vital signs should be charted at least every 5 minutes during the procedure." "As long as I am monitoring the client continuously, I do not need to chart vital signs during the procedure."
"Complete vital signs should be charted at least every 5 minutes during the procedure."
The family of a client who is unconscious following a stroke tells the nurse they feel "pressured" by the resident physician to insert a feeding tube. They are reluctant to agree to the procedure because they believe this action is not something the client would want. Which response by the nurse illustrates ethical practice? "You don't have to do what the resident says. You should talk with the attending physician." "Without a living will or power of attorney, you will not be able to prevent this intervention." "I can arrange for you to talk with the healthcare team about your loved one's situation." "The medical team cannot force you to do anything you don't believe is right."
"I can arrange for you to talk with the healthcare team about your loved one's situation."
The nurse's responsibility concerning informed consent is reflected in which client statement? "I must be fully informed about treatments, tests, alternative treatments, and the risks and benefits of each." "My 14-year-old child may give informed consent to all medical and nursing procedures without my consent." "The healthcare provider and the nurse must each obtain informed consent from me." "If I am declared mentally incompetent, I can give informed consent if I am in the hospital under a mental health regulatory law."
"I must be fully informed about treatments, tests, alternative treatments, and the risks and benefits of each."
A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation? "I need to inform you that your behavior is within the definition of assault." "You need to think of a more creative way to stop the client from playing with the I.V." "You will save the client from another I.V. insertion by restraining the client's hand." "I'm sure the client knows you were joking, but it was still inappropriate to say."
"I need to inform you that your behavior is within the definition of assault."
A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse? "Thank you, this is very generous of you. I'm really humbled by this token of your appreciation." "I'm not allowed to accept gifts of money, but if you wanted to give me something else, that would be acceptable." "Although I can't accept this money, you could just let my supervisor know you're pleased with my work!" "I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift."
"I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift."
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which health care provider order? "Monitor urine output every hour." "Infuse IV fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Draw samples for hemoglobin and hematocrit every 6 hours."
"Infuse IV fluids at 83 ml/hour."
A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which would be the most appropriate response by the nurse to the surgeon? "It is your responsibility to obtain informed consent from the client." "I will get the consent signed right away and attach it to the chart." "I'll have the client sign, but you must explain the procedure before surgery." "I will explain the procedure and call you back if the client won't sign the consent."
"It is your responsibility to obtain informed consent from the client."
A client is being treated for injuries sustained in a motor vehicle collision for which the client was at fault and that resulted in the death of two children. The client does not want to ambulate in the hallway because the client thinks that all the nurses will judge the client for what happened. What is the most appropriate response by the nurse providing care? "I doubt anyone will recognize you, but we can ambulate when the area is quiet." "You cannot control what other people are going to think. I am here to support you." "It sounds like you are feeling guilty about the accident. Do you want to talk about it?" "It sounds like you fear being judged by the staff. Can you tell me more about that?"
"It sounds like you fear being judged by the staff. Can you tell me more about that?"
The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor? "I will have to report to the supervisor if you can't do it." "All clients have a right to compassionate and timely care." "I will take care of any client needs that you can't provide." "Let's discuss how we can meet our clients' needs."
"Let's discuss how we can meet our clients' needs."
A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse? "We will resuscitate the client only if there is a respiratory arrest." "We will continue to use antibiotics to treat the pneumonia." "We will honor the family's wishes because the client cannot make decisions." "We will not provide any pharmacologic intervention at this time."
"We will continue to use antibiotics to treat the pneumonia."
The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate? "While I am happy you are going home, your lifestyle will have to change considerably." "What are your plans for when you get home and back to getting on with your life?" "You sound excited to be recovering from your heart attack! A positive attitude is important" "Do you recall the teaching done by the physiotherapist related to your heart attack?"
"What are your plans for when you get home and back to getting on with your life?"
The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make? "Why are you trying to access that information on the client?" "You should contact the information technology department to let them know." "You are not authorized to view all of the details on the client." "I can pull up the data for you under my log-in information."
"You are not authorized to view all of the details on the client."
A registered nurse (RN) is assigning care on the oncology unit and assigns a client with Kaposi sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). The UAP does not want to care for this client. How should the nurse respond? "I will assign this client to another nurse." "I will help you take care of this client so you are confident with the care." "You seem worried about this assignment." "I will review blood and body fluid precautions with you."
"You seem worried about this assignment."
A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? 1 Unit of glucose 1 bottle of glucose one U of glucose 1U of glucose
1 Unit of glucose
The nurse performs wellness checks in the pediatric clinic. Which child would the nurse assess as demonstrating behaviors that need further evaluation? 2-year old who refuses to be toilet trained and talks to themself 6-year-old who sucks their thumb when tired and has never spent the night with a friend 10-year-old who frequently tells their parent that they are going to run away whenever they argue 2-year-old who is indifferent to other children and adults and is mute
2-year-old who is indifferent to other children and adults and is mute
A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager? Review the nurse's malpractice insurance policy. Address the nurse's omissions as negligent behavior. Ask the nurse whether the client refused the assessments. Reprimand the nurse for being forgetful.
Address the nurse's omissions as negligent behavior.
The nurse is coaching a client about improving their health. Which strategy is the most effective for the nurse to use to help the client take an active role in their health care? Give the client a questionnaire about their health to complete. Provide the client with written instructions about health management. Ask the client about their views of health and health care. Determine if the client has any questions about their health.
Ask the client about their views of health and health care.
A nurse is taking care of two clients who are receiving transfusions of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because they developed dehydration and anemia following pneumonia. After checking the patency of their intravenous (IV) lines and vital signs, the nurse should perform which action next? Call for both clients' blood transfusions at the same time. Ask another nurse to verify the compatibility of both units at the same time. Call for and hang the first client's blood transfusion. Ask another nurse to call for and hang the blood transfusion for the second client.
Call for and hang the first client's blood transfusion.
An unlicensed assistive personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first? Complete an incident report. Wait and observe the client for symptoms of hyperglycemia. Reprimand the UAP for the error. Call the health care provider (HCP).
Call the health care provider (HCP).
Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? Bring a small glass of juice and locate the client. Call the client's health care provider (HCP). Check the computerized care plan to determine what test was scheduled. Send the nurse's assistant to the x-ray department to bring the client back to his room.
Check the computerized care plan to determine what test was scheduled.
The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. Client seems to be very depressed. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway. Client appeared angry and belligerent all shift.
Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway.
A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? Strike through the entry ensuring the original entry is still visible. Rewrite the entry on the correct health record indicating who made the error. Contact the previous nurse requesting that the nurse correct the error. Report to the nurse manager that the nurse needs guidance on documentation.
Contact the previous nurse requesting that the nurse correct the error.
A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? Choose an appropriate infertility treatment method. Acknowledge that only 50% of infertile couples achieve a pregnancy. Discuss alternative methods of having a family, such as adoption. Describe each of the potential causes and possible treatment modalities.
Describe each of the potential causes and possible treatment modalities.
A nurse observes another nurse making social plans with a client and disclosing information of a personal nature. What would the observing nurse do in this situation? Let coworkers know what is going on to have witnesses. Report the observation to the nurse manager. Discuss the observation directly with the nurse. Find out whether the nurse meets with other clients socially as well.
Discuss the observation directly with the nurse.
When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? Have the client's next-of-kin sign the informed consent. Have the client put an "X" on the signature line. Have a court appoint a guardian for the client. Have a hospital quality management coordinator sign for the client.
Have the client put an "X" on the signature line.
When developing the teaching plan for a client who uses a walker, which principle should a nurse consider? The hand bar of the walker should be well below the client's waist. When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. A standard walker needn't be picked up when moved.
If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg.
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? Acute pain related to surgery Deficient fluid volume related to blood and fluid loss from surgery Impaired physical mobility related to surgery Ineffective airway clearance related to anesthesia
Ineffective airway clearance related to anesthesia
A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is a neighbor's son. What action should the nurse take? Inform the nurse director reading the chart is a violation of the client's right to privacy and ask the nurse director to return the chart. Remind the nurse director not to share the client's medical information with anyone because of the client's HIV status. Report the incident to the medical director and document the nurse director's actions. Remind the nurse director that permission from the medical director must be provided before access can be granted.
Inform the nurse director reading the chart is a violation of the client's right to privacy and ask the nurse director to return the chart.
A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? Tell the client that the client should not purchase anything from the nurse. Inform the nurse that selling supplements to clients is a conflict of interest. Interview the nurse's other clients to see if the nurse attempted to sell supplements to them. Report the nurse to the nurse manager and the nursing regulatory body.
Inform the nurse that selling supplements to clients is a conflict of interest.
A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation? Confirm that the client is on the unit but offer no further details. Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Notify security that the visitor viewed confidential client information. Validate the relationship of the visitor to the client before discussing the client's status.
Inform the other nurse that the viewed screen resulted in a breach of confidentiality.
A client is to have a below-the-knee amputation. Before the surgery, what should the circulating nurse in the operating room do? Insert a Foley catheter. Start an intravenous (IV) infusion. Initiate a time-out. Verify that the surgeon possesses the degree of expertise needed.
Initiate a time-out.
A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation? Perform morning care while the client is handcuffed. Insist that the officers stay in the room at all times. Ask another nurse to come into the room. Ask one of the officers to remove the handcuffs.
Insist that the officers stay in the room at all times.
The nurse completes an incident report after discovering and assessing a client sitting on the floor beside the bed. Which actions should the nurse take after completing the incident report? Select all that apply. Notify the physician. Notify the nursing supervisor. Send a copy of the report to the risk management department. Document the completion of the report in the medical record. Document the client's condition.
Notify the physician. Notify the nursing supervisor. Send a copy of the report to the risk management department. Document the client's condition.
A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment? Accept the assignment and not disclose the relationship with the client. Notify the supervisor and provide care until another nurse can be assigned to the client. Notify the supervisor that this is a relative but the relationship will not be a conflict. Ask the aunt if she would like the nurse to take care of her while in the hospital.
Notify the supervisor and provide care until another nurse can be assigned to the client.
An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply. Provide explanations and support to the client. Attend to the client's physical needs. Ask the client to leave. Tell the client their secret is safe. Report any signs of abuse to appropriate agencies.
Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies.
A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? Make sure the UAP has practiced sterile technique on at least one other occasion. Reassign the UAP to a client requiring basic tasks that the UAP has mastered. Supervise the UAP during the treatments involving sterile technique. Provide the UAP with a list of resources to guide the implementation of care.
Reassign the UAP to a client requiring basic tasks that the UAP has mastered.
A nurse and an unlicensed assistive personnel (UAP) are caring for clients in a labor and birth unit. Which task should the nurse assign to the UAP? Perform a fundal check on a 2-day postpartum client. Remove a fetal monitor, and assist a client to the bathroom. Give ibuprofen 800 mg by mouth to a newly postpartum client. Teach a new mother how to bottle-feed their infant.
Remove a fetal monitor, and assist a client to the bathroom.
A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? Monitor the coworker's behaviors. Report the suspicion to the nurse manager. Discuss the suspicion directly with the coworker. Keep track of the quantity of medications in the cart throughout the shift.
Report the suspicion to the nurse manager.
A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch up the child's vaccinations? Contact the child's health care provider (HCP) during office hours. Review nationally published immunization guidelines. Read each vaccine's manufacturer's insert. Ask a local pharmacist on duty.
Review nationally published immunization guidelines.
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing? focus charting SOAP charting PIE charting narrative charting
SOAP charting
A client who does not speak English is to be discharged from the hospital following outpatient surgery. Using an interpreter, the nurse reviewed all postoperative instructions, including the need to come in for the follow-up appointment in 2 weeks. The nurse also explained the reconciled medication list, including when to resume taking each medication and the signs and symptoms that would require a call to the health care provider. To ensure the client will continue ongoing care management, the nurse should do what next? Schedule follow-up visits, and inform the client of dates and times. Provide the reconciled client medication list. Obtain the client's signature following receipt of discharge materials. Provide a copy of the discharge materials to the interpreter.
Schedule follow-up visits, and inform the client of dates and times.
A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first? Notify the physician. Discontinue the I.V. catheter. Administer a ordered diuretic. Slow the I.V. infusion.
Slow the I.V. infusion.
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation? Temperature of 102° F (38.9°C) Minimal serous wound drainage Skin intact over bony prominences Staples intact to incision
Temperature of 102° F (38.9°C)
The nurse is providing care to several clients. In which situation would the nurse be able to accept a verbal order from the healthcare provider? The client is hemorrhaging from a surgical wound. The client has just been admitted to the unit from the emergency department. The client reports new onset headache and has a blood pressure of 90/50 mm Hg. The client is being transported to the cardiac catheterization department.
The client is hemorrhaging from a surgical wound.
A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client? The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. The client will enjoy visits from other clients admitted to the same unit. The client will approach the nurse to ask for a magazine. The client will visit the window outside of the newborn nursery to see the new babies.
The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization.
A young adult client is brought to the ED with their fiancée after being involved in a serious motor vehicle crash. The client's Glasgow Coma Scale score is 7, and they demonstrate evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? The nurse will obtain a signed consent from the client's fiancée because the fiancée is of legal age and the couple is engaged to be married. The health care provider (HCP) will get a consultation from another HCP and proceed with the placement of the ICP catheter until the family arrives to sign the consent. Two nurses will receive verbal consent by telephone from the client's next of kin before inserting the catheter. The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.
The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.
The nurse working with a group of nursing students. What breaches in client care require the nurse to intervene to protect client privacy? Select all that apply. Asking a client's name and date of birth prior to medication administration Attaching client's hospital labels to a laboratory specimen Transporting a client to radiology on the public elevator Keeping the client's door closed during bathing Discussing clients in the cafeteria with other hospital staff
Transporting a client to radiology on the public elevator Discussing clients in the cafeteria with other hospital staff
A nurse is developing a teaching plan for a client who has recently been diagnosed with open angle glaucoma. The healthcare provider ordered pilocarpine 0.25% ophthalmic drops, two drops to eyes each eye four times a day. How should the nurse instruct the client to instill the eye drops? Select the correct order. All options must be used. Close the eye. Using a tissue or cotton gently pull the skin below the eye downward. Wash your hands. Using your finger and a tissue place gentle pressure on the nasolacrimal duct for 30 to 60 seconds. Put two drops into the conjunctival sac of the right eye. Take top off the medication bottle and place on a clean cloth.
Wash your hands. Take top off the medication bottle and place on a clean cloth. Using a tissue or cotton gently pull the skin below the eye downward. Put two drops into the conjunctival sac of the right eye. Close the eye. Using your finger and a tissue place gentle pressure on the nasolacrimal duct for 30 to 60 seconds.
The nurse is triaging trauma clients in an emergency room. Which clients are at risk for developing shock? Select all that apply. a 16-year-old female with a large burn an 84-year-old female with ear pain a 33-year-old male with spinal injuries a 45-year-old male with a fractured finger a 55-year-old male with a sprained ankle
a 16-year-old female with a large burn a 33-year-old male with spinal injuries
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in their urine a client at 37 weeks' gestation who is has insulin-dependent diabetes and is experiencing three to four fetal movements per day a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain a client at 17 weeks' gestation who is not feeling fetal movement at this point in the pregnancy
a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain
The charge nurse is completing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in contact precautions? Select all that apply. a client diagnosed with respiratory syncytial virus (RSV) a client with a new onset of diarrhea a client diagnosed with tuberculosis a client diagnosed with chicken pox a client with a positive wound culture for methicillin-resistant Staphylococcus aureus (MRSA)
a client diagnosed with respiratory syncytial virus (RSV) a client with a new onset of diarrhea a client with a positive wound culture for methicillin-resistant Staphylococcus aureus (MRSA)
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a graphic sheet acuity charting forms medication record 24-hour fluid balance record
a graphic sheet
There has been a car collision involving four vehicles. The nearest emergency department is 30 minutes away. Which client should be transported by helicopter rather than an ambulance to the nearest hospital? a 10-year-old with a simple fracture of the femur, who is crying and looking for their parents a middle-age female with cold, clammy skin and a heart rate of 120 bpm who is unconscious a middle-age male with severe asthma and heart rate of 120 bpm who is having difficulty breathing an older adult with severe headache who is conscious
a middle-age female with cold, clammy skin and a heart rate of 120 bpm who is unconscious
The nurse is assessing clients who are going to surgery today to determine if any client has a possible latex allergy. Which client has the greatest risk for latex allergies? a woman who is admitted for their seventh surgery a man who works as a sales clerk a man with well-controlled type 2 diabetes a woman who is having laser surgery
a woman who is admitted for their seventh surgery
When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face? selecting vocation, becoming financially independent, and managing a home developing leisure activities, preparing for retirement, and resolving empty-nest crises managing a home, developing leisure activities, and preparing for retirement adjusting to retirement, deaths of family members, and decreased physical strength
adjusting to retirement, deaths of family members, and decreased physical strength
Which action performed by a nurse will increase the risk of liability? Select all that apply. witnessing a client sign a consent for an ordered medical procedure withholding a medication to clarify the ordered dosage assisting a client on ordered bed rest to walk to the toilet asking unlicensed assistive personnel to assess a client's wound providing information to a caller about a client's diagnosis and treatment
assisting a client on ordered bed rest to walk to the toilet asking unlicensed assistive personnel to assess a client's wound providing information to a caller about a client's diagnosis and treatment
Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting? democratic permissive laissez-faire autocratic
autocratic
The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions? delegation networking clinical coordination advocacy
delegation
When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply. wearing a gown and gloves when in room encouraging client turning and repositioning every 2 hours having call bell within easy reach having four-sided rails up when client is in bed initiating hospital fall risk protocols
encouraging client turning and repositioning every 2 hours having call bell within easy reach initiating hospital fall risk protocols
Because of an outbreak of influenza among the nursing staff, the hospital is very short-staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? rescheduling surgeries ensuring that clients receive medications but omitting full bathing when possible allowing all medications to be given 2 hours late asking unlicensed assistive personnel (UAPs) to assist in administering analgesics
ensuring that clients receive medications but omitting full bathing when possible
Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when the nurse reflects on the decision-making process and the role it will play in making future decisions? evaluating diagnosing planning implementing
evaluating
The nurse in the health care provider's office is teaching a 58-year-old male client, with heart failure, about a new prescription for spironolactone due to increasing fluid retention. Complete the following sentence by choosing from the lists of options. The nurse explains that taking spironolactone places the client at risk for: hyperkalemia hypernatremia hypercalcemia and that the client needs to: avoid dairy products avoid foods high in potassium increase intake of sodium chloride
hyperkalemia avoid foods high in potassium
A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up on the incident with other members of the care team
identifying risks and ensuring future safety for clients
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes limiting abbreviations to those approved for use by the institution using only abbreviations whose meaning is self-evident to an educated health professional ensuring the abbreviations are understandable to clients who may seek access to their health records using those abbreviations defined in full at another location in the client's chart
limiting abbreviations to those approved for use by the institution
In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? orders for antibiotics orders for diagnostic studies orders for dietary changes orders for respiratory treatments
orders for antibiotics
The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed? adhesive strips petrolatum gauze 4 x 4 gauze moist saline
petrolatum gauze
The nurse is placing a client with severe neutropenia on neutropenic precautions. The nurse should tell the client that neutropenic precautions will prevent the spread of organisms in which way? preventing the spreading of organisms to the client from sources outside the client's environment limiting the transfer of organisms from the client to health care personnel and visitors disposing of contaminated materials in marked containers keeping the client's linens and personal items in the room
preventing the spreading of organisms to the client from sources outside the client's environment
In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning? providing client teaching assessing the client's needs and identifying problems developing goals with the client making home healthcare referrals
providing client teaching
When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method? pulling the ear pinna back, up, and out pulling the ear pinna back, down, and out pulling the ear pinna out pulling the ear pinna down
pulling the ear pinna back, up, and out
A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment? speech therapist respiratory therapist physical therapist physician
speech therapist
A client with a platelet disorder has a platelet count of less than 150,000/μL (150 × 109/L). The nurse should instruct the client to avoid which activity? walking for more than 10 minutes straining to have a bowel movement visiting with young children sitting in the semi-Fowler position
straining to have a bowel movement
When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present
that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications
The client had an ostomy created 3 days prior. The nurse is planning to teach the client how to empty the ostomy pouch. What is the best time for the nurse to conduct the teaching? the time that the nurse and client mutually agree upon just prior to the end of the nurse's shift at the time the nurse perceives he or she will have time to conduct the teaching before the client's lunch
the time that the nurse and client mutually agree upon
The nurse on an inpatient medical unit is caring for a 92-year-old male client, admitted from an assisted living facility, for evaluation of failure to thrive following a hip fracture 6 months ago. The client is alert and oriented to person, place, and time and has had a 6% weight loss, lack of appetite, and limited mobility. TPN thyroid hormone levels CT scan of head PSA level dietary consult physical therapy evaluation complete bed rest blood type and cross match Fill in the Blank The nurse anticipates that the provider will order ................, ................., and ......................... for this client.
thyroid hormone levels dietary consult physical therapy evaluation
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to prevent medication errors to ensure client safety to make it easier for clients to understand the medication prescriptions to make data entry into a computerized health record easier
to ensure efficient and accurate communication to prevent medication errors to ensure client safety
A nurse is discussing principles in healthcare ethics with the nursing students. Which would be an appropriate example of nonmaleficence? to protect clients from a chemically impaired practitioner to perform dressing changes to promote wound healing to provide emotional support to clients who are anxious to administer pain medications to a client in pain
to protect clients from a chemically impaired practitioner
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP's prescriptions? Contact the HCP and: suggest adding potassium to the fluids. request an increase in the volume of intravenous fluids. verify the prescription for 5% dextrose in water. determine if the client should be placed in isolation.
verify the prescription for 5% dextrose in water.
A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to change their own dressing with clean technique and be able to verbalize the steps. walk with help in the hallway by the end of the evening shift. walk from their room to the end of the hall and back before discharge. select special foods from a diet after client education by the nurse.
walk from their room to the end of the hall and back before discharge.
The nurse on a medical unit is providing discharge instructions to a 52-year-old male client, diagnosed with Clostridioides difficile (C. diff), about preventing the spread of this infection at home. Fill in the Blank To prevent the spread of infection at home, the nurse teaches the client and family to ............., ............., and ............. wash hands with soap and water for 15 seconds wash hands at least once each day wash hands with soap and water before eating or preparing food wash hands with soap and water after using the toilet use alcohol-based sanitizer for handwashing use bleach to clean surfaces in the home
wash hands with soap and water before eating or preparing food use bleach to clean surfaces in the home wash hands with soap and water after using the toilet